Integrated Care Specialist

Job Description

Job Description

Position Summary:

The Integrated Care Specialist supports care coordination between primary care and behavioral health services in accordance with North Carolina Clinical Coverage Policy 8 and Advanced Medical Home (AMH) Tier 3 standards. This role emphasizes patient engagement, telehealth facilitation, and compliance with Community Care of North Carolina (CCNC) integrated care practices. Key responsibilities include reducing no-show rates, ensuring seamless care transitions, leveraging technology for health monitoring, and promoting culturally responsive care.

The position plays a vital role in empowering patients to make informed decisions about their health and aligns with Southeastern Integrated Care’s (SEIC) mission to deliver accessible, integrated, and person-centered healthcare.

Essential Duties and Responsibilities:

Direct Patient Support

• Monitor patients’ health status, medication adherence, and safety, supporting autonomy and self-management.
• Respond to urgent patient needs and coordinate appropriate interventions, including EMS dispatch or activating the Remote On-Call Direct Support Professional (DSP).
• Troubleshoot smart home and wearable technology to support in-home health monitoring.
• Provide instruction and ongoing support to patients and families on using telehealth and remote monitoring technologies.
• Track and respond to alerts from wearable devices for patients outside the home to maintain care continuity and safety.

Patient Engagement & Scheduling

• Actively contact and reschedule patients to reduce no-show rates in primary care clinics, following CCNC protocols.
• Collaborate with enhanced care team leads to ensure timely follow-up for patients in need of primary care services.
• Arrange transportation for medical and behavioral health appointments to eliminate access barriers.
• Foster inclusive, culturally sensitive communication, and involve families or guardians in patient care planning when appropriate.

Telehealth & Virtual Care Coordination

• Coordinate and schedule telemedicine visits in accordance with NC Clinical Coverage Policies 1H, 8A, and 8D.
• Send appointment links, manage scheduling logistics, and resolve technical barriers to support successful virtual encounters.
• Assist patients with accessing telehealth platforms and ensure proper documentation in the Electronic Health Record (EHR) following AMH Tier 3 requirements.

Hospital Discharge & Transitional Care

• Monitor and track patient hospital discharges, ensuring timely entry of discharge summaries and follow-up care in the EHR.
• Work with clinical teams to support post-discharge planning and continuity of care, in accordance with CCNC transitional care standards and payer requirements.

Documentation & Quality Assurance

• Maintain timely and accurate documentation of all patient interactions in the EHR.
• Participate in internal audits and quality improvement initiatives aimed at improving care coordination, telehealth access, and patient engagement.
• Collect and monitor data related to no-show rates, care transitions, and virtual visit metrics to inform performance improvement efforts.

Operations & Regulatory Compliance

• Adhere to all applicable NC Clinical Coverage Policies (1H, 8A, 8D), AMH Tier 3 standards, CCNC practices, and SEIC protocols.
• Identify and report suspected abuse, neglect, exploitation, or adverse events in accordance with state requirements.
• Participate in required trainings and staff meetings related to crisis response, smart technology, and integrated care.
• Maintain knowledge of emergency protocols and assist during crisis events as needed.

Other Duties

• Support additional initiatives as assigned by the supervisor, including community outreach or preparation for regulatory audits and reviews.

Qualifications and Education:

Minimum Requirements

• High school diploma or GED.
• Basic proficiency in navigating technology platforms including EHR systems (Athenahealth preferred) and telehealth platforms.

Preferred Qualifications

• Associate or bachelor’s degree in a health-related field.
• 1–2 years of experience in a primary care, behavioral health, or integrated care setting.
• Experience working with smart technology or providing patient/caregiver training.
• Familiarity with NC Clinical Coverage Policies and AMH Tier 3 practices.
• Previous experience as a paraprofessional or in a supportive healthcare role.

Skills and Competencies

• Strong organizational, communication, and customer service skills.
• Ability to work independently while also collaborating within interdisciplinary teams.
• Culturally responsive approach with commitment to patient-centered care.
• Adaptable and tech-savvy, with a problem-solving mindset.

Required Certifications & Training

• CPR, First Aid, Bloodborne Pathogens
• Medication Administration and Client Rights
• Nonviolent Crisis Intervention (NCI) or Therapeutic Behavioral Management
• Crisis Management and Incident Reporting
• Training on Substance Use, HIV/AIDS, STDs, and Drug Screening
• Education on Domestic Violence, Sexual Abuse/Assault, and Confidentiality

Work Environment

• Office-based with travel to clinic or home settings as needed.
• Frequent phone and virtual interactions with patients and care teams.
• May involve exposure to home environments including pets, smoke, or noise.
• Standard workweek with occasional flexibility for after-hours engagement or urgent patient support needs.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed primarily in the client’s living environment and in the community and may involve exposure to cigarette smoke, domestic animals/pets, household pests, uncomfortable heating/cooling, and other issues related to the domestic location in which service is delivered.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand, walk; use hands to finger, handle, or feel objects, tools, or controls; talk and hear; and taste and smell. The employee frequently is required to reach with hands and arms and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit and climb or balance. The employee must be able to lift and/or move up to 20 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Must be able to drive and operate a personal vehicle safely and adhere to all applicable state and traffic laws.